HISP - Health Information Systems Programme

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HISP - Health Information Systems Programme 1.
Research and development in the health
sector South-South-North software development
action research - Funding through NUFU donors
/health authorities in individual
countries 1994/96 - started in South
Africa 1998/99 started in Mozambique 2000/01 sta
rted in India, Malawi 2002/03 - Tanzania,
Ethiopia, Nigeria, Namibia, Vietnam, etc 2.
Educational program Funding through Norad
QUOTE A. PhD program across academic fields
focusing on HISP Students from participating
universities registered at UiO B. Integrated
Masters programmes in Informatics and public
health in South Africa and Mozambique (Tanzania
partly Malawi) C. Continuous education and
training of health workers and managers Developmen
t introduction of ICT require massive
training! Training schemes base in the Masters
programs
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The Problem Unify and integrate fragmented
structures and information flows - The health
sector is crippled by uncoordinated vertical
structures
DNHDP Western Cape
City Health
Births Deaths Notifiable diseases
New /emerging flow of information
City Health Clinic 3
City Health Clinic 1
Groote Schuur Hospital
Outside hospitals
City Health Clinic 2
City Health Clinic 4
School Health
Geriatric Services
PAWC
MOU (Midwife obstetric unit) PAWC
Day Hospital DNHPD
City Health Clinic 5
DNHDP Pretoria
Private hospital 31 medical specialists
Psyciatric hospital PAWC
Environmental office
Dental unit 1 PAWC
54 private medical pract.
RSC
Dental unit 2 PAWC
23 private dental pract.
UWC Oral Health Centre
Dental unit 3 PAWC
12 private pharmacies
12-15 NGOs
Mandalay Mobile clinic RSC
Youth Health Services
MITCHELLS PLAIN
Apartheid legacy a fragmented and top down
health structure no local governance control
of information
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Two registration forms of activities/patients
representing same events
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Information from other sources, e.g. Birth /
death registers TB register, census data,
socio-economic data
Higher levels
HEALTH PROGRAMS
Local Government
Nutrition
COMMUNITY STRUCTURES
V E R T I C A L
C O M M U N I T Y
DISTRICT HEALTH MNG. TEAM
TB
Health Welfare Forum
Unions
STD/ AIDS
Health Committees
DISTRICT INFORMATION SYSTEM DATABASE
Family planning
Special Interest Groups
School Health
Traditional healers
Referrals
Day hospitals
Clinics
NGOs (Non-gov. Organisations)
Private Sector
Dental Services
Psychiatric services
Circumcision Surgeons
Environmental Health
Maternity/ Midwife units
NON-GOVERNMENT
GOVERNMENT
HEALTH SERVICES
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Background Started in South Africa 1994
/ HISP

• The Health Information Systems Program (HISP) has
  been part of developing the Health Information
  System in South Africa since 1994
• developing software (DHIS),
• training programs,
• district based health information systems,
• indicators, data standards
• models for use of information for action
• Best practices software from South Africa later
  spread and further developed to a number of
  countries in Africa Asia
• Since 2005 EU /BEANISH supported and strengthened
  thisBEANISH /HISP network

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/ HISP
South Africa - Legacy of apartheid Inequity
fragmentation - Step 1 Focus on MUST know
information integration at district level
Higher levels
Health programs
Mother Child
Database Info. office
A
B

• South Africa
• Post-apartheid Inequity and fragmentation
• - No shared information resources
• - Process of standardisation based on
• Key information needs indicators,
• data sets reporting structures

B) South Africa Integrated model- Shared
information Between and within health
structures - Focus on information for action -
Continuous training
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Botswana 2005 onwards .
/ HISP

• National Health Information System dysfunctional
  2 years backlog of poor quality data
• Rich health programs develop their own systems
  (HIV/AIDS, Infectious disease reporting,
  vaccination etc.)
• Poor programmes have nothing, e.g. Mother
  Child
• Fragmentation no coordination and overview of
  key data and indicators
• ADDRESSING THESE PROBLEMS
• Integration data warehouse (DHIS) at district
  national levels
• Starting integration at district level
  All data reported through the districts

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/ HISP
Botswana Pre-intervention Fragmentation No
shared IST resources converging at district
level - Fragmentation at central level
IDSR Notifiable Diseases
EPI
Home Based Care
ARV
Health Statistics
PMTCT
STD
Nutrition
Nutrition
Family Planning
MCH
HIV/AIDS
TB
School Health
Mental Health
And more
District - DHT
Facility 1
Facility 2
Facility n
Facility 3
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/ HISP
Botswanaintegration at District National
levels learning from South Africa
IDSR Notifiable Diseases
EPI
Home Based Care
ARV
Health Statistics
PMTCT
STD
Nutrition
Nutrition
Family Planning
MCH
HIV/AIDS
TB
School Health
National HMIS Stat. unit
Mental Health
And more
District HMIS
Facility 1
Facility 2
Facility n
Facility 3
But Adding data-warehouse to the model from
South Africa
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Introduction to (Health) Information Systems (1)

• What is Information Systems?
• Wide understanding from cell-phones to card
  based filing systems in a library - or in a
  clinic - AND the SOCIAL ORGANISATION OF IT!
• Information and Communication Technology - ICT
  OR just IT (Information Technology) - An even
  wider definition
• Technology is rooted in people (knowledge) not
  things organisation, knowledge, learning,
  innovation - as well as artefacts
• Information Systems are best understood as social
  systems
• a web of social and technical elements
• nothing in a technological system is poorly
  technical (non-human)
• the information system is part of the social
  context
• information systems in a clinic (registers,
  forms, reports, information handling, meetings)
  may be seen as a human activity system

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Introduction to (Health) Information Systems (2)

• Large Information systems / and IT / ICT may be
  seen as information infrastructure
• Infrastructure has a wider meaning the technical
  grid (roads, wires, hospitals, cold chain/EPI,
  etc.) as well as the institutions, support
  systems, organisations, schools, training etc.
  necessary to run and maintain it.
• Information systems make up a web of more or less
  interacting information systems - more or less
  integrated through standards / lack of standards
• Web - network metaphor
• Develop over time - makes changes difficult
• Health Information Systems Health Information
  Infrastructure

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Introduction to (Health) Information Systems (3)

• The installed base - what is already there -
  the point of departure
• Information Infrastructure develop and grow over
  time
• As the installed base grow it becomes
  increasingly difficult to implement changes
• Always something there beforehand - never
  possible to start from scratch
• Information Systems Social Systems gt
• Information infrastructure web of social
  systems
• Installed base social-technical web /existing
  information infrastructure

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Introduction to (Health) Information Systems (4)

• Information systems as Social Systems
• Consequences for system development design???
• Focus on people and not technical artefacts -
  design and development need to be based on the
  social system
• Participation in design and development
• Local ownership and commitment need to evolve
• Leadership to the users!! (Politics?)
• The existing social system - the people already
  there, their skill, capacity and motivation -
  will form the basis for development
• HUMAN RESOURCE DEVELOPMENT - Training and
  support!!!

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Introduction to (Health) Information Systems (5)

• Information systems as Information Infrastructure
  
• Consequences for system development design???
• Everything is part of something bigger - or rely
  upon something else
• Development needs to involve negotiations with
  many other systems
• Standards and interfaces with other systems (e.g.
  different health programs)
• A more comprehensive approach is
  neededdevelopment of health information
  infrastructure relies upon the wider
  infrastructureThe wider network of training and
  support of hardware, software and humanware
  needs to be developed together with the health
  information infrastructure

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Introduction to (Health) Information Systems (6)

• The installed base - brings together social
  systems and infrastructure in an unruly mess
• Consequence for change-planning - system
  development change??? i.e. Health sector
  reform?
• Changes tend to be incremental and piecemeal
• When planning for change - a lot of historical
  commitments (ways things have always been done)
  will stand in the way
• A web of social systems represent obstacles to
  change

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Introduction to (Health) Information Systems (7)

• Health Information Infrastructure
• reflection mapping of the health sector
• - institutions, services, health programs
• Hospital information systems
• Patient based registers, paper / computer based
  based / electronic patient journals
• Drugs /pharmacy
• Transport
• Finance
• Laboratories
• Tuberculosis
• Extended Programme on Immunisation (EPI)
• Sexually Transmitted Diseases
• Surveillance Notifiable diseases - rapid
  response
• Death / Birth registers

• Human resources
• Primary Health Care Information Systems
• Environmental health/ water / sanitation
• Epidemiological information systems
• School health
• Personnel /salary
• etc. etc. etc. etc. etc.

• Patient billing
• health insurance
• tele-medicine
• etc. etc.

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Introduction to (Health) Information Systems (8)

• Health Information Infrastructure
• flow of information reflection mapping of
  the health sector
• - institutions, services, health
  programs Vertical - centralist - top-down
  -structure

National level Provincial level District
level Facility level
National Health Information System (SIS)
TB STD Mother EPI Rural Nutrition
Notifiable Drugs Transport Child
Hospitals diseases
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Introduction to (Health) Information Systems (9)

• Health data the health facility is the entry
  point for all data!
• - Quality of data at the facility level
  crucial for all information at all levels
• - garbage at the facility level - garbage
  everywhere!!

• Events (patient - facility) counted and
  registered daily - when happening
• registers (e.g. per health program), books,
  files, forms
• green (deliveries), red (children), yellow
  (adults) etc. beans put in a bottle
• tally sheets with pictures
• tally sheets with text
• computers - patient record system
• Aggregating data and reporting upwards every
  month (typically) at the facility
• data reporting forms
• huge amount of forms - one for each health
  program, or
• Minimum Dataset based forms (e.g. South Africa)
• Keeping/organising the data at the facility
• Paper in a file organised or disorganised
• computer - spreadsheet - or database

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The role of information and problems with the
action led approach 1. How is it possible to
solve problems outside the scope of health
management? 2. May information make an
difference? Influencing Decision making with
different information approaches 3 Decision
making outside routine formalised areas will
often rely upon mobilising support from a wider
range of actors
Problem area - Health for all Primary
Health Care provision
e.g malnutrition infant mortality
Scope of (political) action by Community other
actors
scope of action for health management
Comprehensive approach action-led
approach
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1. The action-led approach Developed by a
collaborative research project in Kisarawe in
Tanzania Ministy of Health, African Medical
Research Foundation, Liverpool School of
tropical Medicine, Superior institute of health,
Rome. Ministry of Health, Tanzania (1991)
Sandiford et al. (92, 94) Influential within
health information - much cited A. Define the
scope of decision-making by level of
management B. Provide information C.
Act! Focus who are the users and specific
information needs Information must be analysed
and used at the level it is generated If
action is the aim It is as important to know how
a decision may be made - how to use the
information - as to know what decision should be
made
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Increasing Maternal Mortality at peripheral
levels in Mongolia - following the economic
crisis break down of Soviet Union

• Problem
• rest-houses used 2-4 weeks prior to delivery
  were closed
• lack of equipment in district hospitals
• poor ambulance service /lack of petrol
• Solution
• Opening up rest housesEquipment training in
  its use
• improve ambulance services

Actors and factors National health management,
WHO, INFORMATION international donors (money),
district hospitals equipment skill
training Petrol ( - gt general economic
crisis) Bssically within the (international)
health system - apart from petrol
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Uneven distribution of nurses in 6 clinics in
Mitchells Plain

• Solution move nurses between clinics
• Actors involved
• (or to be enrolled)
• in efforts to rectify the problem
• health management
• nurses
• unions
• information
• All within the scope of the
• health services ?

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Nutritional status among children in Khayelitsha
in relation to housing and services as water and
toilets - Housing level of services have
impact on health SOLUTION Build houses develop
general infrastructure
Problem the health sector is not building
houses toilets - not action-led
information? Scope of action - actors - needs
to be extended ActorsHealth sector, Community
groups, Non Governmental Organisations Environment
al sanitation water sectors, local government
(ANC), provincial government. INFORMATION., etc.
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• Information as information - the rational of
  the information system
• Feldman and March (1981) provide four useful
  explanations for the often observed
  over-consumption and lack of use of
  information
• Organisations provide incentives for gathering
  extra information. These incentives are buried
  in conventional rules for organising, as the
  division of labour between information gathering
  and information using.
• Much of the information in organisation is
  gathered and treated in surveillance mode rather
  than decision mode the focus is on negative
  trends, which trigger action.
• Much of the information in organisations is
  subject to strategic misrepresentation.
• Information use symbolises a commitment to
  rational choice.

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• Information as institutional glue- a
  consequence (but not purpose) of information
  systems
• Information as trust, relationship and (social)
  structure
• The structures and ideology instituted by the
  information systems make up considerable
  obstacles to change
• The processes and structures being
  institutionalised - or structurated - by the
  information systems often seem to be their most
  important property and outcome
• As a concequence
• using information system as a tool for
  structurating new structures - e.g. the new
  health district Let the changed/ transformed
  information system produce - and through
  routine activities re-produce the new
  organisational structures